Policy

Trump wants to repeal Obamacare. What of payment reform, ACOs, innovation?

Both sides in the Obamacare debate have valid points. They also are only seeing the tip of the iceberg.

Obamacare

Throughout the contentious campaign, Donald Trump repeatedly called Obamacare a “disaster” and promised to repeal it immediately upon taking office.

“On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare,” Trump stated on his website. He also said he would replace the Affordable Care Act with “a series of reforms ready for implementation that follow free market principles and that will restore economic freedom and certainty to everyone in this country.”

Since the Patient Protection and Affordable Care Act passed in March 2010, Republicans took back control of the Senate that year and have voted more than 60 times to repeal all or parts of the legislation — at a cost of at least $87 million. President Obama vetoed every attempt that made it to his desk.

Republican President-elect Trump will enjoy Republican majorities in both houses of Congress for at least the next two years, so it’s a pretty safe bet at this point that the ACA is toast.

Trump and other ACA opponents have long pointed to rising healthcare premiums and out-of-pocket costs, reduced competition in health insurance and narrower provider networks as reasons to roll back Obama’s signature legislative accomplishment.

Supporters of Obamacare have warned that a repeal could shock the system by pulling health insurance away from 10 million or more people. In addition, it would allow insurance companies to resume denying coverage based on pre-existing conditions.

Both sides have valid points. They also are only seeing the tip of the iceberg.

The Affordable Care Act contains 10 major sections, or titles. Only the first two and parts of the third, sixth and ninth cover what pretty much everyone outside of policy and legal circles generally refer to as Obamacare, the parts that deal with health insurance. Remember, health insurance is not the same as healthcare, and having insurance does not guarantee good care.

Title IX addresses how to pay for the ACA, including through taxes on medical devices, pharma manufacturing, tanning salons and “Cadillac” insurance plans. The unpopular device tax has been suspended for two years, as has the Cadillac tax.

The only area actually dealing with care that has gotten much public attention is Title VI. This section addresses fraud and abuse, particularly in Medicare and Medicaid, and sets up the Patient Centered Outcomes Research Institute. PCORI and what used to be known as comparative effectiveness research are where the ridiculous notion of “death panels” came from.

But the rest of the ACA is a mystery to probably 90 percent or more of the general public.

Title IV deals with public health. Title V talks about the healthcare workforce and expanded community health centers — something that hits right at the heart of access to care. Title VII authorized the Food and Drug Administration to set rules about biosimilar biologic drugs.

Title VIII incorporated an earlier, standalone bill called the Community Living Assistance Services and Supports (CLASS) Act that was to set up a long-term disability insurance program. The Obama administration in 2012 abolished the office that was implementing the CLASS program, and legislation enacted at the very beginning of 2013 repealed this title.

Title X reauthorized the Indian Health Care Improvement Act for Native Americans and Native Alaskans.

Title III is probably the most relevant part of the ACA when talking about actual healthcare reform. That is the part that authorized Medicare to move away from inefficient and often dangerous fee-for-service reimbursement to value-based purchasing. It set up the important policy that withholds Medicare payments to hospitals for certain preventable readmissions.

This area of the law also set guidelines for Accountable Care Organizations and created the Medicare Shared Savings Program as well as the Center for Medicare and Medicaid Innovation. Notably, the ACA gave CMS, via the Innovation Center, the power to ramp up pilot projects that were successful; previously, CMS could only run small-scale demonstrations and then would have to go back to Congress for permission to expand any program that worked.

Most of the ideas in Title III are reshaping American healthcare for the better and saving taxpayer money on Medicare. So Trump and congressional Republicans had best tread lightly. They risk throwing out the baby with the bathwater by doing completely away with something simply because it is so closely tied to Obama.

Photo: Flickr user Charles Fettinger

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